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CAQH CORE Voluntary Certification National Webinar:
Roadmap to HIPAA Conformance:
Is CORE Certification Right for your Organization?
An EHR Vendor Perspective
June 25th, 2015
2:00 – 3:00pm ET
2© 2015 CAQH. All rights reserved.
• Welcome & Introduction
• Voluntary CORE Certification: Entities that Can Become CORE-Certified
• MEDITECH: CORE Certification Phase I & II
• Voluntary CORE Certification: Getting Started
• Edifecs Conformance Testing Portal
• Q&A
Session Topics
3© 2015 CAQH. All rights reserved.
• Download a copy of today’s presentation on
the CAQH.org website
− Navigate to the CAQH CORE Education Events
page and access a pdf version of today’s
presentation under the list for today’s event
• The phones will be muted upon entry and
during the presentation portion of the session
• At any time throughout the session, you may
communicate a question via the web
– Submit your questions on-line at any time by
entering them into the Q&A panel on the right-
hand side of the GoToWebinar desktop
– On-line questions will be addressed first
• There will be an opportunity today to submit
questions using the telephone
– When directed by the moderator, press the
“raise hand” button to join the queue for audio
questions
Participating in Today’s Session
4© 2015 CAQH. All rights reserved.
© 2015 CAQH. All rights reserved.
Voluntary CORE
Certification: Entities that Can
Become CORE-Certified
5© 2015 CAQH. All rights reserved.
Why Certify?
• In an environment of heightened enforcement, healthcare organizations are
concerned about having systems that are compliant with government
requirements and having trading partners and vendors with compliant
systems.* Examples of evolving enforcement:
– ACA-mandated HHS Health Plan Certification (proposed)
– ACA-mandated Audits
– New CMS Division: Division of Administrative Simplification Compliance
• Administrative time and cost savings: Smoother ongoing use and industry
transition to new federally mandated standards and operating rules results in
more immediate and widespread cost savings
– Many in industry attribute implementation difficulties to a lack of a consistent
testing process or framework**
*65% of Practice Management Buyers are looking to replace existing medical software. The most common reason for replacing existing practice management or billing systems was that they weren’t
confident their current systems achieved regulatory compliance. (Medical Practice Management Software Buyer View 2014).
** See the September 21, 2012 letter to HHS from NCVHS: ”Re: Findings from NCVHS Hearings on Administrative Simplification in June 2012 – an update on Heath Care Administrative Care
Administrative Transactions.” See also, “Transaction Compliance and Certification: A White Paper Describing the Recommended Solutions for Compliance Testing and Certification
of the HIPAA Transactions,” prepared by the Workgroup for Electronic Data Interchange (WEDI) Transactions Workgroup, March 10, 2010.
6© 2015 CAQH. All rights reserved.
What is Voluntary CORE Certification?
• CORE Certification is the most robust and widely recognized industry
program of its kind. It employs a multi-faceted, independent approach to
demonstrating conformance with CAQH CORE Operating Rules
– Requirements developed by broad, multi-stakeholder representation through a
transparent discussion and polling process
– Requires conformance testing by independent third party testing vendors that are
experts in EDI and testing
– CAQH CORE serves as a neutral, non-commercial administrator:
• Authorizes the conformance testing vendors
• Reviews applications and conformance test reports before Certification is awarded
• Award and display of a CORE Certification Seal
– Allows entities to publicly communicate their conformance to their trading partners,
their customers, and the broader healthcare industry, while promoting
administrative simplification
– All CORE-certified entities know what to expect of other CORE-certified entities
– Is proposed by HHS as a Document of Compliance in ACA-mandated Certification
of Compliance Proposed Rule
7© 2015 CAQH. All rights reserved.
Entities that Can Become CORE-Certified
Health Plan
Stakeholder Types
Provider Stakeholder
Types
Clearinghouse
Stakeholder Types
Vendor Solutions or
Products
HIPAA-covered
Health Plan
HIPAA-covered
Provider
Clearinghouse as
defined by HIPAA
Health Plan vendor
service
Third Party
AdministratorsPhysicians
Clearinghouse (not
covered by HIPAA)
Health Plan vendor
product
Health Insurance Issuer HospitalsHealth Information
Exchange Provider vendor service
Government Payers,
including Medicaid
Plans
Provider’s agentHealth Insurance
Marketplaces or
Exchanges
Provider vendor plan
Group Health PlanIndependent Physician
AssociationFinancial Institution
Health Plan Agent
8© 2015 CAQH. All rights reserved.
Why Entities Get CORE-Certified
Health Plan Stakeholder
Types
Provider Stakeholder
Types
Clearinghouse
Stakeholder
Types
Vendor
Solutions or
Products
• Give assurance of their
conformance with federally
mandated operating rules
• Inventory whether their
systems, and the
systems of their
business associates,
are conformant
• Add value for current customers
and attract new ones
• Position themselves as
leaders in administrative
efficiencies
• Expedite a better
patient experience and
increase patient
satisfaction
• Meet a trading partner contract
expectation; being asked of by
both health plans and providers
• Lower cost within their claim
processing system
• Ensure their revenue
cycle is the most cost
effective
• Message to their clients of
commitment to effective claims
processing and/or revenue cycle
management
9© 2015 CAQH. All rights reserved.
CORE Certifications Awarded by Stakeholder Type
• Major national entities that have achieved CORE Certification include:
Health Plan
Stakeholder Types
Provider Stakeholder
Types
Clearinghouse
Stakeholder Types
Vendor Solutions or
Products
10© 2015 CAQH. All rights reserved.
Certification of Vendor Products: The “Slipstream” Effect
A Vendor’s Customers can “Draft” behind a Vendor Product’s CORE Certifications:
When a non-HIPAA covered EHR/PMS company obtains CORE Certification for its
product…
• It gives its customers assurance that the product is conformant with the federally-
mandated operating rules, AND
• It gives its customers the opportunity to leverage that Certification and become
CORE-certified as well
11© 2015 CAQH. All rights reserved.
Polling Question #1:
Voluntary CORE Certification
Do you anticipate that your organization will become CORE-certified?
1. Yes
2. Unsure
3. No
4. Not applicable to my stakeholder type
5. Already CORE-certified
MEDITECHCORE Certification: Phase I and II
Presented by: Christine Sher, Senior Analyst for Regulatory ComplianceKyle MacLennan, Lead Software Developer for Interoperability
● Founded in 1969
● More than 2,300 facilities worldwide
● Over 3,900 employees
● Revenues of $517 million (2014)
● 38 consecutive profitable years
● 5A1 Dun & Bradstreet credit rating
● Employee owned, privately held
7/2011 - Began tracking the operating rules outlined in the Affordable Care Act (ACA)
10/2011 - Started technical evaluation of CAQH CORE Operating Rules for Eligibility and Claim Transactions(Certification not required. ARRA/Meaningful Use priority.)
5/2013 - Received request from customers
Timeline
5/2013 - Received request for MEDITECH to consider certification● George Conklin, Senior VP/Chief Information Officer at
CHRISTUS Health and Board Chairman for CAQH CORE● MEDITECH and CHRISTUS Health partnership for over 20
years ● 25 inpatient facilities in TX and LA using MEDITECH, totaling
approximately 4,800 beds
Strategic Decision
● Collaborated with CHRISTUS Health staff too Evaluate current interface useo Prioritize project development
● CAQH CORE Phase I and II for “EDI Eligibility Validation – Version Client/Server 5.66”
● CAQH CORE Phase II for “Claim Status Inquiry and Response – Version Client/Server 5.66” (NEW)
● CAQH CORE Phase III for Electronic Claim Submission/Remittance – Version Client/Server 5.66”
Strategic Decision(cont.)
“We want healthcare providers to know that
whenever they exchange administrative data they
can depend on real-time access to information
needed to make timely and informed decisions.”
Howard Messing, CEO and President of MEDITECH
Benefits of Certification
● Ensure interfaces meet current Operating Rule standards
● Allow for CHRISTUS and other customers to become CORE-certified
● Enhance interoperability between providers and
payers
● Ensure customers ease of use and compliance
Benefits of CORE Certification
START HERE!!!
CAQH CORE
http://corecertification.caqh.org/CORE_voluntary
● CORE Certification: A Step-By-Step Process
● FAQs about CORE and CORE Certification
1. Pre-certification Planning and Systems Evaluation - Obtain and
review testing data in order to determine MEDITECH's ability to meet
requirements and scope of project
2. Signing and Submitting the CORE Pledge
3. MEDITECH Project Development/Coding/Testing
4. CORE Certification Testing - MEDITECH works with a CAQH CORE-
authorized testing vendor, Edifecs, to complete Pre-Testing, Testing
and Post-Testing
5. Applying for the CORE Seal - Complete necessary application and pay
CORE Seal Fee
Project Plan and Milestones
Coding:
● Allocation of resources with existing certification projects and committed release scheduleo 31 Days to update Eligibility Validation interfaceo 138 Days to design, code and test Claim Status
Request/Claim Status Response
● Learning curve specifically with Connectivity
Challenges
Testing:
● Learning curve with testing process
● Conformance testing, rather than “productionreadiness”
● Response time for questions and issues
Challenges
● Everything we needed was provided by CAQH CORE or Edifecs
● Testing process was at our own pace
● Saw an instant benefit of processing speed
Definitely our preferred way to certify!
Kudos!
25© 2015 CAQH. All rights reserved.
© 2015 CAQH. All rights reserved.
Voluntary CORE
Certification:
Getting Started
26© 2015 CAQH. All rights reserved.
Who Can get CORE-Certified and for What?
• Voluntary CORE Certification is offered to:
– Any entities that create, transmit, or use the administrative transactions
– Specific vendor products or services that enable providers, health plans or
clearinghouses to carry out HIPAA-required standard transactions
• CORE Certification Testing is Stakeholder-Specific:
– Each entity completes testing specific to their stakeholder type to become CORE-
certified so testing is relevant to entity’s business processes and eliminates non-
applicable requirements
• 186 CORE Certifications have been achieved to date. Access a list of these
organizations HERE.
• Is available for the following transactions:
– Eligibility (Phase I)
– Eligibility and Claim Status (Phase II)
– Electronic Funds Transfers (EFT) and Electronic Remittance Advice (ERA) (Phase
III)
Learn more about voluntary CORE Certification here
27© 2015 CAQH. All rights reserved.
Voluntary CORE Certification:
A Step-by-Step Process
Step 1:
Step 2:
Step 4:
Step 3:
Pre-certification Planning
& Systems Evaluation
• Understand requirements of the CAQH CORE
Operating Rules and scope your internal efforts to
adopt and implement the CAQH CORE Operating
Rules
• CAQH CORE has free Gap Analysis Tool
• Execute any necessary system changes/updates
Sign and Submit
CORE Pledge
• Formally communicate your intent to pursue
CORE Certification for a given phase of
CAQH CORE Operating Rules
CORE Certification
Testing
• An entity seeking CORE Certification works
with a CORE-authorized testing vendor to
perform tests based upon CORE Phase I-III
testing criteria specific to that entity’s
stakeholder type
Apply for CORE
Certification Seal
• Entities successfully achieving CORE
Certification will receive a CORE “Seal” from
CAQH that corresponds with the CORE
Phase and stakeholder-type
NOTE: If the entity seeking CORE Certification outsources any portion of the applicable transactions to a trading partner, then
that trading partner must become CORE-certified for that transaction in order for the seeking entity to complete the CORE
Certification process
28© 2015 CAQH. All rights reserved.
Voluntary CORE Certification Testing:
Types of Test Scripts
CORE Certification Testing is comprised of stakeholder-specific
test scripts for each CAQH CORE Operating Rule
Conduct the actual transaction for which
you are testing with the CORE-certified
testing vendor
Upload specified document to the
testing site as proof of compliance
Along with other specified documentation,
an entity must sign an attestation signifying
their current or planned compliance
Attestation
Upload
System
Transaction
29© 2015 CAQH. All rights reserved.
Notice of Proposed Rule Making (NPRM)
published in Federal Register, January 2, 2014
• As of June, 2015, a final rule had not been published
CORE Phase III Certification
Seal
Framework: Conformance Testing
• Involves Testing with Independent
Testing Entity
• Part of the established Voluntary
CORE Certification Process
HIPAA Credential*
Framework: Attestation
• Requirements outlined in NPRM
• Involves coordination with trading
partners
• Draft forms here
OR
In its Proposed Rule, HHS turned to
CORE Certification as a Health Plan
Certification Compliance Option
*May be adjusted pending final rule
ACA-mandated HHS Health Plan Certification
30© 2015 CAQH. All rights reserved.
If you would like to find out more about
CAQH CORE Certification, contact us at:
CORE@CAQH.org
31© 2015 CAQH. All rights reserved.
Polling Question #2:
CORE Certification of Trading Partners
How many trading partners is your organization aligned with to meet
compliance with the federally mandated operating rules?
1. None
2. One to Three
3. Four to Twenty-Five
4. Twenty-Five +
5. I don’t Know/Does not apply
Edifecs Conformance Testing Portal
Carrie M. Bauman
Edifecs Compliance Solutions
Carrie.Bauman@Edifecs.com
Edifecs CAQH CORE Partnership
• CAQH CORE-authorized Testing Vendor for CAQH CORE Operating Rules Phases I, II and III
• Helping healthcare organizations with voluntary CORE certification testing since 2006
• 186 (and counting!) CORE Certifications as of June 2015
• Partnering with CAQH CORE for industry education sessions
Pathways to Partnerships
Agenda slide 1. CORE certification
project timeline
2. Tips for getting
prepared for
conformance testing
3. Signing up for the
Edifecs conformance
testing portal
4. Basic portal navigation
Pathways to Partnerships
CORE Certification Testing Timeline
• Review
CAQH CORE
Operating
Rules
• Review
CAQH CORE
Gap Analysis/
Identify
transaction
content gaps
• Perform
technology
replacement
analysis
• Baseline
current
performance
levels
• Make necessary
technology
replacement
decisions
• Implement new
technologies • If needed
• Make system
changes
• Access CAQH
CORE
educational tools
to assist with
implementation
(CORE@CAQH.
org)
• Perform internal
testing• Unit testing
• Regression
testing
• Verify
compliance with
content and
infrastructure
compliance rules• Functional testing
• Integration
testing
• Track service
levels• Volume
• Load
• Develop project
plan, submit
Pledge to
CAQH CORE,
register with
Edifecs
• Download and
set up master
test data
• Iterative testing
until successful
completion of
testing program
• Application
review by
CAQH CORE
and award of
Seal
• Go live!
• Constant
surveillance
ensuring
compliance with
service levels
Prepare Yourself for Testing
Review, understand and analyze the following
components of CORE Certification in depth provided by
CAQH CORE
• CORE Testing Policy
• CAQH CORE Operating Rules and their applicability
• Master test bed data for CORE Testing
• CORE Test Suite cases
On the connectivity side making sure that your system
follows the requirements specified in the connectivity
specification provided by CAQH CORE.
• Note: The testing entities system must be up to date and
conformant with the CAQH CORE Operating Rules
connectivity (Phases I/II/III) prior to testing
1
2
Navigation from CAQH CORE Web Siteto Edifecs CORE Conformance Testing Portal
http://www.caqh.org/ http://corecertification.caqh.org/CORE_certification
http://corecertification.caqh.org/CORE_voluntary
Navigation from CAQH CORE Web SiteTo Edifecs Conformance Testing Portal
http://www.edifecs.com/login/core-phase-i-ii
http://www.edifecs.com//login/core-phase-iii
Navigating from www.edifecs.comTo Edifecs Conformance Testing Portal
http://www.edifecs.com/login/core-phase-i-ii
http://www.edifecs.com//login/core-phase-iii
Edifecs Conformance Testing PortalQuick Start Guide
Edifecs Conformance Testing PortalCreate ID + Login
Edifecs Conformance Testing PortalSet up Wizard
Edifecs Conformance Testing Portal
Edifecs Conformance Testing PortalWrapping up and acknowledgement
Pathways to Partnerships
Keep Educating Yourself
Request a copy of the Quick Start Guides
Carrie.Bauman@Edifecs.com
Want to learn more about conformance testing? Sign up for
the Operating Rules Blog
www.edifecs.com/e/
Follow Edifecs on LinkedIn
https://www.linkedin.com/company/edifecs
Visit Edifecs.com for the latest information on helpful
conformance testing and ongoing monitoring solutions
www.Edifecs.com/solutions/compliance-solutions/operating-rules/
Pathways to Partnerships
Additional Edifecs SolutionsDe Facto Experts in CORE Conformance Testing for 10 Years
• Connectivity
• Transaction Workflow
• Enrichment
EdifecsAssessment Framework
EdifecsOperating Rules
Solution- Connectivity
- Transaction Workflow
- Enrichment
EdifecsOperating Rules
Extended Testing Solution
EdifecsOperating Rules
Solution- Surveillance
- Service Level Tracking
Pathways to Partnerships
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50© 2015 CAQH. All rights reserved.
Polling Question #3
CORE Certification Educational Tools
What types of educational tools do you prefer to learn about things like CAQH
CORE Operating Rules and CORE Certification? (Pick one or more)
1. These kinds of webinars
2. Text documents (white papers, “how to” guides)
3. Short informational videos (less than 10 minutes)
4. Presentations by organizations that have gone through the process
5. Newsletter-type emails
51© 2015 CAQH. All rights reserved.
Please submit your question:
• Via the Web: Enter your question into
the Q&A pane in the lower right hand
corner of your screen
Q&A
52© 2015 CAQH. All rights reserved.
Please submit your question:
• By Phone or VoIP: When prompted for
audio portion of Q&A, please press
“Raise Hand” Button to queue up to ask
a question
Q&A
NOTE: In order to ask a question during the audio
portion of the Q&A please make sure that you have
entered the “Audio PIN” (which is clearly identified on
your user interface) by using your telephone keypad.
53© 2015 CAQH. All rights reserved.
Top Takeaways:
• An EHR Vendor, such as MEDITECH, views CORE Certification as a
way to demonstrate to healthcare providers that all administrative data
exchanges it undertakes are dependable, real-time and interoperable
• CORE Certification adds value to both HIPAA-covered and non-HIPAA
covered entities and products, and gives assurance to conformance
with federally mandated operating rules to trading partners using those
services and products
• Voluntary CORE Certification is a widely recognized industry program
that assures conformance with federally mandated operating rules,
adds value to an organization’s IT systems or products, and promotes
a return on investment through administrative cost savings and
attraction of new clients
• The CORE-authorized Testing Vendor Edifecs supports customized
CORE Certification Testing specific to an organization’s stakeholder
type
54© 2015 CAQH. All rights reserved.
Thank You for Joining Us!
We value your opinion. Please complete the online feedback
survey at the end of this webinar.
website: www.CAQH.org
email: CORE@caqh.org
@CAQH